Strategies to reform health financing and boost partner coordination in Niger

Strengthening health financing and partner collaboration in Niger

The Republic of Niger, a landlocked country in West Africa, has faced decades of armed conflict and persistent droughts, severely straining its healthcare system. With some of the highest maternal and infant mortality rates globally, the nation has prioritized universal health coverage (UHC) as a national objective. This commitment follows earlier efforts to expand access to essential health services, particularly in response to the country’s alarming health indicators.

In 2006, recognizing the urgency of the situation, the Government of Niger introduced a bold free healthcare policy targeting women and children under five. This initiative provided free reproductive health services, family planning, and essential pediatric care. While initial progress was promising, insufficient funding—amounting to only half of projected needs by 2011—created significant challenges. Unpaid medical bills accumulated, hindering service delivery and forcing other patients to bear exorbitant out-of-pocket expenses. The World Health Organization (WHO) reports that direct payments account for over 40% of total health spending in Niger.

Despite modest improvements—health expenditures rose from 4.9% to 5.6% of GDP between 2016 and 2018 before stabilizing around 5.7% from 2018 to 2020—the country continues to struggle with sustainable financing for health initiatives.

Partners unite to address funding gaps

Before implementing the free healthcare policy, Niger had already recognized the importance of collaboration among health financing partners. In 2006, the Ministry of Health, the French Development Agency (AFD), and the World Bank established the Health Joint Fund (FCS) to support the country’s health development plan. By 2020, additional international partners joined, including UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID).

However, funding shortfalls and misaligned resource allocation under the free healthcare policy highlighted the need for systemic reforms. This prompted the Government to pursue a more coordinated approach to health financing, leveraging global partnerships like Providing for Health (P4H), a global health financing and social protection network active in Niger since 2018.

In 2021, members of P4H and signatories of the Global Action Plan for Healthy Lives and Well-being for All (SDG 3 GAP) collaborated to appoint a national focal point. This role, supported by Gavi and funded through the Global Financing Facility (GFF), aims to enhance coordination between health partners and align technical and financial support with national priorities. By January 2022, Gavi officially assumed the role of co-rapporteur for health financing partners, further strengthening the Government’s ability to lead health sector reforms.

The national focal point serves as a bridge between the Ministry of Health and external partners, helping to harmonize funding and streamline project implementation. Previously financed by WHO with AFD support, the position’s funding model has transitioned to the World Bank, with GFF exploring co-financing mechanisms to ensure long-term sustainability.

Key reforms to modernize Niger’s health financing system

Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health at the GFF, emphasizes that fragmented funding historically led to both underfunding and inefficient overfunding of initiatives in Niger. The P4H and SDG 3 GAP partnership has fostered greater collaboration, enabling partners to align their support with broader social protection programs and budgetary reforms that improve health outcomes for women and children.

In 2020, health financing partners prioritized support in areas such as COVID-19 response, domestic resource mobilization, resource optimization, and cross-sectoral investments. The Government identified key priorities, including:

• Aligning budgetary support with harmonized health expenditure indicators.
• Reforming the FCS to enhance its fungibility and transition from a management tool to a financing system.
• Implementing strategic procurement with technical assistance from the National Institute of Medical Assistance (INAM).
• Improving the predictability of partner contributions and annual activity planning.

To achieve these goals, several targeted activities were launched:

• Financing harmonization:
  • Mapping donors, funding flows, and health financing channels, with critical analysis of coordination efforts (supported by GFF).
  • Evaluating the future trajectory of the FCS (supported by WHO/P4H).
  • Developing investment case financing channels (supported by GFF).
• Support harmonization:
  • Reviewing and analyzing technical assistance for health financing.
• Financing systems and tools:
  • Assessing operational models for free healthcare and universal health insurance strategies (supported by WHO/P4H, AFD, and FCS).
• Efficiency and optimization tools:
  • Developing and deploying a cost simulation tool for health service production and financing in rural areas (supported by AFD, FCS, and GFF).
  • Identifying low-cost innovations in primary healthcare delivery through bottom-up health system reforms (supported by AFD, FCS, and the Global Fund).
• Domestic resource mobilization and expenditure allocation:
  • Engaging with the International Monetary Fund (IMF) to integrate health expenditures, such as vaccination and nutrition, into indicative target frameworks.
  • Advocating for increased allocation to primary healthcare and immunization during high-level missions and SDG 3 GAP meetings with the Government.

Additional support is required to refine technical committees within the Ministry of Health, streamline program-based budgeting reforms, and develop policy proposals to enhance national financing efficiency.

Measurable impact and future outlook

While still in its early stages, this collaborative financing strategy is expected to significantly improve health service delivery. Moussa Bizo of the WHO Niger Office notes that the GFF’s resource optimization approach helps identify and track funding flows, reducing duplication and enabling more targeted interventions. This method could also allow partners like the Global Fund and Gavi to allocate resources more strategically toward HIV, tuberculosis, malaria, and immunization programs—all covered under the free healthcare policy. Ultimately, these reforms aim to reduce out-of-pocket expenses for vulnerable populations by strengthening INAM’s operational capacity.

Overcoming challenges and sustaining progress

Joint focal points integrated into the Ministry of Health and funded sustainably add value by facilitating alignment and coordination among partners. This is particularly critical in Niger, where a significant portion of health financing comes from external sources.

Despite strong enthusiasm, challenges persist. Focal points in partner organizations face heavy workloads, risking the initiative’s long-term viability. Ensuring dedicated staff time and clarifying long-term funding mechanisms for the national focal point are essential priorities. The GFF has extended funding by six months, and Gavi is facilitating discussions with additional partners to secure sustainable financing for health in Niger.

Lessons from this pilot partnership will be shared with other countries and organizations to meet the growing demand for joint focal points and more harmonized, coordinated health financing support.

Understanding the SDG 3 Global Action Plan

The Global Action Plan for Healthy Lives and Well-being for All (SDG 3 GAP) is a collective commitment by 13 leading health, development, and humanitarian agencies to accelerate progress toward health-related Sustainable Development Goals (SDGs). By fostering collaboration, the SDG 3 GAP aims to deliver more coordinated, country-led support aligned with national strategies. Updated in October 2021 with a fair and sustainable recovery strategy post-COVID-19, the plan underscores the need for integrated, resilient health systems to achieve equitable health outcomes globally.